HUMAN RELATIONS, AUTHORITY AND JUSTICE: EXPERIENCES AND CRITIQUES
THE POLITICS OF MENTAL HEALTH IN BULGARIA: IS THERE A CIVIC ROLE FOR PSYCHIATRY?
One of the unforeseen changes in Sofia, the capital city of Bulgaria, which followed upon this country's hesitant onrush away from totalitarianism and onto civic society, was the rapid increase in the number of homeless dogs. They roam in hundreds the littered streets of this polluted city of about one million inhabitants, who are stacked in high rise cheap blocks of flats deprived of grace, comfort and privacy. Early mornings are a particularly difficult time for the homeless dogs because then pets of distinguished breeds are taken to the streets and arrogantly claim the greens and other territories between the blocks that constitute the natural habitat for the homeless dogs. One Saturday morning while heading for my office across a park in the city centre I spotted again this vigorous young off-spring of a German Shepherd whose intelligence and beauty had impressed me on previous encounters. He was very good at avoiding the expensive cars recklessly driven by felons-turned-men-of-power, who killed and injured street dogs unabashedly. I had also observed that there was a dignity, rather than servitude about him while responding to those who cared to take notice of him. On this particular occasion he was howling from a distance at a group of prosperous looking men walking their dogs. The group had a glow of success around them and displayed contempt at all outside their circle. The sound of his voice was pained, his front paws were strained, his neck stretched. His despair was at the intrusion of man in the world of dogs, which introduced a division against all fairness and precluded all quest of meaning. The pain of the marginalised.
This episode illustrates amply the frustrated feelings that I and many other psychiatrists have in Bulgaria daily while facing our patients, their relatives, our nursing and other staff, our students and associates, our colleagues from other branches of medicine. It is about the experience of being destined to fail, of being identified with failure as such and thus provide the base line for everybody else's measure of success. It is about accepting the identity of the loser, about becoming reconciled to it, about developing and reinforcing a personal identity of a loser, and about resisting urges to drop and reconsider this identity. My purpose will be to demonstrate that in the aftermath of communism the mental health field in Eastern Europe is left with the legacy of an unbridgeable division along an ill-conceived dimension of normality. I will argue that professional psychiatric associations in Eastern Europe should develop the potential to reclaim from those who have pronounced immutable the lines of division between mental ill-health and mental well-being the right to re-cast them from the position of professional independence. I hope to demonstrate that this is a priority in the politics of mental health and requires political action as well.
Some History
The Society of the Bulgarian Psychiatrists had been created after a blueprint for learned societies developed by the party/state apparatus of the previous regime and was by virtue of the design intended to re-iterate opinions and injunctions formed elsewhere. It was subsidised to add scientific gloss to such statements. At its 1990 General Assembly meeting the Society of the Bulgarian Psychiatrists failed to elect its governing bodies and its dissolution became imminent.
The Bulgarian Psychiatric Association (BPA) came into existence in 1991 as a result of the efforts of an initiative committee which called a constituent assembly in line with the country's new legislation which re-introduced the right to associations. Soon afterwards it was registered under the law.
The statute and by-laws of BPA stipulate that the Association shall provide a voice to the profession. In these documents BPA vows to co-operate fully with the Bulgarian Medical Association, which had been restored after a 40 year ban, on matters of professional ethics and discipline and on protecting the interests of its members. The Association also pledges to act as a learned society in the field of psychiatry and mental health by fostering training and research and by setting standards of professional performance.
An over-riding concern at the constituent meeting had been power and the potential of its abuse. This had triggered long debates about adopting procedures that would prevent as much as possible the concentration of decision making in the hands of one person for a long time. To that end the constitution clearly stipulates the prerogatives of the Body of Governors and those of the Executive Board. It introduces rotation on an annual basis for the key position of President and vote by ballot. It allows within limits representation in the member societies of psychiatrists-in-training and clinical psychologists. The Association has its bulletin, holds annual meetings and collects fees from its members. It seeks and accepts sponsorship from institutions, individuals, local authorities and foundations. It regularly invites pharmaceutical companies to present and exhibit at the conferences which the association holds. The Ethics Committee of the Association is independent of the Board of Governors and is elected by ballot at the annual meetings of the General Assembly.
Meeting with Indifference
Nobody seemed to think that the new Association made a change. The response of the Ministry of Health was cool and disinterested and stayed so for a succession of three cabinets. The university departments of psychiatry were only marginally stirred by the event. The Educational Board was likewise unperturbed by this development. The medical directors of psychiatric hospitals were interested in the new association initially, before it became clear that it did not command power of political, economic, bureaucratic, or other nature.
To summarise, at the time of its appearance nothing seemed to indicate that the Association was coming to fill in a void. Quite the opposite: the cards had been dealt a long time ago between Health, Education and Academia, and the three sectors taking care of the mental health field, clients and providers included, did not in any way indicate that they needed another partner, such as the Association, or that they even took it seriously. BPA had its first lesson in living under democracy: it had been brought forth uncomissioned, so it had to secure a niche for itself in a totally disinterested environment of haughty partners.
There was no immediate realisation within the Association of the nature of the experience it was confronted with. The interpretations and the responses of the different individuals differed. Most widespread was the response of withdrawal after a volley of activities. In practice this found expression in a rapid drop in the rate of attendance and participation in the initiatives of the Association.
In the second place the variety of goals and tasks which the Constituent Assembly had so generously pledged to pursue was drastically reduced, and the Association found itself performing the well familiar role of a learned society, conducting scientific meetings. This was an activity that all members felt at home with. The division of roles was clear: some presented and some acted as the audience. All the intrigue was in whether in the course of time people got re-located from the one role into the other and who those people were.
Thirdly, and significantly, some started forging an image and a future for a psychiatric association in Bulgaria in the aftermath of a totalitarian regime. I feel that this is a most interesting development and will concentrate on it.
The Psychiatric Reform as a Source of Identity
At its 1994 annual meeting the General Assembly of the association, in summarising the results and the conclusions, stated the importance of the psychiatric reform, conceived broadly as de-institutionalisation, to the identity and future of the Association. This insight was picked up by a group of members and was developed into a document, which was widely circulated in Bulgarian and English. This document drew attention to the internalised, in terms of psychic structures, consequences of life under total control. Briefly, the document argued that as a result of a systematically enforced policy over decades, the psychiatric profession had seized to regard itself as empowered or even capable of opinions, judgements, decisions or even considerations concerning itself and its own field. The document, called "Toward the Liberation of Mental Health", attempted to make it understood that Bulgaria had to perform its own brand of de-institutionalisation starting with the profession of psychiatry itself. Bulgarian psychiatrists had to bring themselves to admit that it did not feel right for a profession not to be approached when decisions were made about the priorities in the field of this same profession, or about its standards of professional performance, or about the promotion of people to senior and academic positions from among the profession. Bulgarian psychiatrists had to acquire the faculty of feeling that the profession should have a say in decisions like the above, and that if this were not the case, it would be only natural for all who considered themselves "the profession" to feel that things were not as they should be.
In the months that followed the psychiatric reform in Bulgaria gradually began to be identified with a variety of interrelated activities performed on behalf of BPA, which attempted to claim back into the profession psychiatrists from all kinds of positions, commitments, careers, posts, appointments and the like and get them re-gain their primary professional identity. Reform became the hall mark of the Association and made it noticeable by the bureaucracies. The progress is slow and difficult, like learning a new skill. Three major areas of activities are illustrative: provision of psychiatric services, training for the mental health professions and publishing.
In the field of service provision members of the Association who run innovative programmes were asked to present the profiles of their services at meetings of the Association. Topics were raised, like tutoring, clinical supervision, case management, and multidisciplinary team work, all of them telling examples of reformed thinking in that they all concern a stance to service provision, characterised with assuming personal responsibility for the work done. Demands were addressed at these meetings to the university departments of psychiatry to incorporate these topics in their training programmes. Shortly afterwards the Psychiatric Department in Sofia undertook to revamp its whole strategy to postgraduate training by pronouncing for the first time tutoring and clinical supervision as primary training methods in the field of mental health and psychiatry.
In the field of training BPA became involved in advocacy for the granting to the professions of Social Work, Psychiatric Nursing and Clinical Psychology university degree status, and thereby, the right to practice clinical work with full professional responsibility. This campaigning is akin to abdication from exclusive professional rights in the mental health field and is seen as a sign of incipient professional humility, and therefore, soundness.
BPA got involved in very active search for the right professional texts to be translated and published in Bulgarian. It is now a partner in a network of activities that bring out psychiatric and mental health books on the market which fill in a professional and cultural void.
It is gradually becoming apparent that currently BPA is involved in a variety of ways in disentangling the profession of psychiatry in Bulgaria from norms and values imposed on it by a malign all-penetrating bureaucracy, which is concerned with its own self-perpetuation and not with the field of mental health and which constitutes an extreme form of institutionalism.
What is Ahead
Bulgaria is still loosing its good minds and its young people to the West. Psychiatry is no exception. Individuals who had been doomed under the previous regime to become losers because had happened to question the established practice, now have the freedom to leave the country. It is still not possible to disagree, to challenge the establishment and after been refused access to participation, to stay on and create an alternative practice. BPA it seems got involved in making this possible. Some call this political involvement, some call it civic. Whatever you may wish to call it, it is expanding rapidly.
Paper delivered to symposium on 'The Role of the Professional Psychiatric Associations' (GIP sponsored symposium); 25 August 9.00-9.30 a.m. X World Congress of Psychiatry, Madrid, 23-28 August, 1996
Copyright: The Author
Address for corrwespondence: Medical Academy, 15 Dim. Nestrov, 1431 Sofia,
Bulgaria, Mental Health Centre <ttbb@sf.cit.bg>